PROOF OF RECYCLING

Proof of recycling is established when the retailer, contractor, delivery service provider, or recycling facility provides a receipt that
demonstrates a consumer’s action to replace an old appliance. This form may be used in place of a recycling receipt provided by the
retailer, contractor, delivery service provider, or recycling facility to establish proof of recycling.

Section A – Required Ohio Residential Consumer Information

Consumer Name: ___________________________________________________________________

Street Address: ____________________________________________________________________

City: _____________________________________ Zip Code: ________________________

Type of appliance accepted from consumer (submit one form per rebate redemption application):

□ Refrigerator □Dishwasher □Clothes Washer □Water Heater

Section B - Select the option that applies to how the appliance was recycled

□ Section B-1 – Appliance Collected at Residence by Haul-Away Service

Providers, Appliance Installers, Contractors
Service Provider Name: _____________________________________________
Street Address: _____________________ City: _____________________________
Zip Code: ________________________ Phone #: ( ) ____ - ______
Collection Date: _____/_____/ 2010

Deliver Collected Appliance to: ____________________________________ (Recycling Facility)

□ Section B-2 – Appliance Collected from the Consumer at Recycling Facility

Recycling Facility Name: _______________________________________

Street Address: ______________________________________________

City: ________________________ State: _____ Zip: ___________ Phone: __________________

Collection Date: _____/_____/ 2010

□ Section B-3 – Appliance Collected by Local Community Program

Community Program Name: ____________________________ Collection Date: _____/_____/ 2010

Section C – Certification of Recycling

By signing this form, the consumer and/or the recycling facility, haul-away service provider, or appliance installer identified above certifies
that the appliance collected from the consumer will be disabled and recycled. This certification is being given to satisfy a requirement of
the Ohio Energy Efficient Appliance Rebate Program and will be relied upon by the State of Ohio as evidence of the proper disposal of
the collected appliance.

Service Provider/Recycling Representative (sections B-1 or B-2): ___________________________________

(Print Name)
Signature________________________________________
Date: _____ /_____ / 2010
Customer Agreement: _________________________________________________________
(Signature)